Outpatient Physical Therapy - understanding healing Claim Modifiers - The Modifier -25, -24, -51, -57, -59, -26
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I am writing this description again as a suggestion from many of my readers on my blog. This description is more uncut in a way that scenarios were cited to have a bigger look on the allowable use of some of these leading modifiers.
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How is understanding healing Claim Modifiers - The Modifier -25, -24, -51, -57, -59, -26
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Outpatient Physical Therapy.
In this article, I will be describing the healing claims modifiers - Modifier -25, -24, -51, -57, -59, -26.
Modifier -25, 25: Significant, separately identifiable evaluation and administration assistance by the same physician on the same day of the procedure or other service:
This modifier must be appended with an E/M service. This is the modifier you will need to use with the evaluation and administration assistance done on the same day with other procedure done by the same physician. It has to be above and beyond the usual preoperative and postoperative encounter with the procedure. In fact, by using this modifier, it doesn't have to have a distinct determination reported. The most leading thing is that, the E/M level should meet its key components or if it is superior based on time with the sick person (counseling and coordination). You have to be true in using this modifier. It must meet healing necessity. As you know, there are procedures that already includes all other care and management.
Let's delineate this modifier 25:
A sick person came in for her monthly consequent up for her lasting back pain. At the same time, sick person was complaining with severe headache. The pain physician performed bilateral occipital block on the sick person at the time of service. You will append modifier 25 for the E/M code to indicate that both services were rendered on the same day.
You don't use modifier 25 with E/M encounter that resulted to Decision for surgery (we have other modifier for this!)
Modifier -24, 24: Unrelated evaluation and administration assistance by the same physician while postoperative period.
As the modifier indicates, this is other modifier that you can only append with an E/M counter. It indicates that the E/M encounter is not related while the global period.
Let's delineate this modifier 24:
A pain specialist performed facet nerve destruction for the patient. while the normal, postoperative global period, the sick person came in to the office with severe knee pain due to fall on ice as evidenced by the patient's subjective information. The pain specialist will then description that E/M encounter with the sick person by appending modifier 24 to indicate that encounter is not related while the postoperative global period.
This modifier, like modifier 25 has no restriction as with the level of E/M code as long as it meets healing necessity, all its components or are time-based.
Modifier -57, 57: Decision for Surgery:
An evaluation and administration assistance resulted in the initial decision to perform surgery while the E/M encounter.
Let's delineate this modifier:
An Ob/Gyn sees a sick person who complains with severe abdominal pain. It turned out (through ultra sound, radiology and all other diagnostic testing and documentations), the sick person is having an ectopic pregrancy. The Ob/Gyn performs the laparoscopic surgery on the same day. The E/M encounter will then be reported with modifier 57 which resulted to decision for surgery. The laparoscopic surgery should also be reported as performed on the same day without a modifier.
Modifier -50, 50: Bilateral Procedure
You will append modifier 50 for procedures that are obviously billable as bilateral (or two sides, both sides), performed on the same day, the same operative session, on identical anatomical sites, organs (arms, legs, spine).
A Facet Nerve block is unilateral (can be billed as bilateral). When using a modifier 50, make sure you only bill for one unit on the claim form since there is only 1 procedure is performed bilaterally. Though guidelines from other payers may differ. They may require you to list it twice (line 1 and line 2 on the claim form). You have to be responsible to explain this with your payors.
You use this modifier with add-on codes too! Do not use this modifier with procedures which are already described as bilateral procedures.
Modifier -51, 51: multiple Procedures
This modifier is used when reporting multiple procedures performed by the same physician on the same day. Do not use this modifier for "add-on" codes (see appendix D of the Cpt Code book). Do not use this modifier for codes with "modifier -51 exempt" symbol (see appendix E of the Cpt Code book). Do not use this modifier with an E/M code. This modifier can only be used by the same physician on the same day who performed the procedure.
Coding tip: List the top reimbursable code (after the main procedure code) based on the fee schedule.
Modifier -59, 59: unavoidable Procedural Service
Description of Modifier -59: Under unavoidable circumstances, the physician may need to indicate that a procedure or assistance was unavoidable or independent from other services performed on the same day.
Modifier 59 is used to recognize procedures/services that are not normally reported together, but are accepted under the circumstances. This may characterize a distinct session or sick person encounter, distinct procedure or surgery, distinct site or organ system, detach incision/excision, detach lesion, or detach injury (or area of injury in uncut injuries) not ordinarily encountered or performed on the same day by the same physician. However, when other already established modifier is appropriate, it should be used rather than modifier 59. Only if no more visible modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.
Use this modifier only if the other procedure is a separately identifiable procedure code. procedure that is unavoidable and can be described as independent procedure, on detach anatomical site, lesion, injury site, distinct organ system, and distinct session. Do not use this modifier for E/M code.
Modifier -26, 26: pro Component
This modifier is used only for the pro component (physician) of a assistance or a procedure. unavoidable procedures are a aggregate of both pro and technical component. By using modifier 26, it indicates that procedure being reported as pro component only.
Professional Component versus the Technical Component. By illustration, procedures rendered at a installation such as sick person hospital or Asc, these equipments are facility-owned. The installation will then description the technical component for such assistance while the physician will description the pro component for the that procedure. One very good example, the physician performs Paravertebral Facet Block under Fluoroscopic advice using Cpt code 77003. The physician will description the fluoro with modifier 26 for his/her pro component. While the installation will description the the same procedure with modifier -Tc for the technical component.
Modifier -Lt or -Rt are used to indicate a Left or Right side or anatomical site. So if the pain specialist performed Left Cervical Facet Block, you will append a modifier -Lt to description this procedure.The above modifiers are used to delineate your claims for the services performed on the sick person for accepted payment. Always consult your local careers and third party payors for local determination, policies and guidelines on these modifiers. Finding at the edits is also very important!
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